Nokea
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?
- A. Evaluate for asterixis
- B. Palpate for peripheral edema
- C. Evaluate for decreased level of consciousness
- D. Inspect for petechiae
Correct Answer: B
Rationale: Peripheral edema occurs with hypoalbuminemia due to decreased oncotic pressure causing fluid leakage into tissues.
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A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5 mg/kg/dose subcutaneously every 12 hours. The client weighs 245 lbs. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 167
Rationale: Calculation: 245 lbs ÷ 2.2 = 111.36 kg; 111.36 kg × 1.5 mg/kg = 167 mg
A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?
- A. Sodium level
- B. Intake and output
- C. Daily weight
- D. Tissue turgor
Correct Answer: C
Rationale: Daily weight is the most reliable measure of fluid retention as 1 kg weight gain equals approximately 1 liter fluid retention.
A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).
- A. Tachycardia
- B. Rebound tenderness
- C. Rigid abdomen
- D. Elevated blood pressure
Correct Answer: A,B,C
Rationale: These are classic signs of perforation and peritonitis: tachycardia from pain/stress, rebound tenderness and rigidity from peritoneal irritation.
A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C?
- A. A client who works in a child care center
- B. A client who eats raw shellfish
- C. A client who has multiple tattoos
- D. A client who has recently traveled to an underdeveloped country
Correct Answer: C
Rationale: Tattoos with non-sterile equipment are a risk factor for HCV transmission.
A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).
- A. Profuse vomiting with fecal odor
- B. Epigastric abdominal distention
- C. Intermittent abdominal cramping
- D. Ribbon-like stools or diarrhea
- E. Metabolic acidosis
- F. Severe fluid and electrolyte imbalance
Correct Answer: A,B,C,D,E,F
Rationale: All are potential findings in LBO due to mechanical obstruction, bacterial overgrowth, and fluid shifts.